Entertainment Media Can Help Change Behaviors and Stop the Ebola Outbreak

In the wake of the current Ebola crisis, the 2011 movie Contagion (See the trailer here) directed by Steven Soderbergh has repeatedly been cited as one of the best examples of a movie taking on the subject of pandemic disease and managing to educate while providing gripping entertainment. This is no coincidence. Contagion was produced with both A-list stars (Gwyneth Paltrow, Matt Damon, Laurence Fishburne, Kate Winslet, and others) and support from leading public health experts such as Dr. Ian Lipkin who is the inspiration for one of the scientists portrayed in the film, and award-winning writer Laurie Garrett, author of several books including The Coming Plague. Participant Media, founded by Jeff Skoll to inspire social change through entertainment, was a producer, with the Skoll Global Threats Fund, World Health Organization (WHO), and U.S. Centers for Disease Control and Prevention (CDC) providing input as well.

The tagline from the film is “No One is Immune…to Fear.” While one of the early scenes is of a woman dying of a flu-like illness (played by Paltrow) the movie elicits fear not from gruesome symptoms but instead from plot lines and messages that focus on how human responses to these types of public health crises make matters worse. It also showcases the valuable work done by epidemiologists and other public health workers who are the heroes of this film. Contagion communicates these and other lessons effectively using the power of story, a subject recently discussed on this blog.

It’s one thing to have a government official or medical professional describing (usually dryly) how a pandemic can spread and what precautions to take. It’s another altogether to become transported through a story in a movie (or television or radio program) to a virtual reality where it’s possible to vicariously experience a pandemic threat and its consequences. For example, when one of the main characters, Dr. Erin Mears played by Winslet, discusses the ease with which the virus in the movie Contagion is spread, “The average person touches their face three to five times every waking minute. In between that we're touching door knobs, water fountains, and each other….” viewers instinctively cringe and become aware if they are biting their nails or rubbing their eyes.

Contagion is an example of entertainment education (EE) - the use of entertainment media to inform, educate and support behavior change. Entertainment education is effective because narratives or stories are emotionally powerful – they help us to organize information and to create the “mental models” that we use to make sense of the world and can help to explain why we behave in particular ways. Mental models are one of the central themes of the forthcoming 2015 World Development Report which focuses on how and why people take decisions, including some that appear contrary to their own self-interest. The report also highlights research on entertainment education. In some cases, the stories or mental models that people adopt are based on misinformation and misunderstanding. For example, in the current Ebola crisis doctors coming to care for the sick have been viewed by understandably wary villagers as the cause of the illness and threatened with violence if they did not leave. This has hampered efforts to treat patients and safely dispose of the bodies of those who have died, adding to the risk of further infection. Other potentially risky practices, such as eating bush meat, especially fruit bats and monkeys which may be carriers for the virus, have also proved resistant to change. Of course it is not just ignorance about risks that drives bush meat consumption. In too many areas, meat from livestock is not available or is too expensive, often because veterinary services are absent or so weak that huge losses to disease are the norm.

There is an urgent need for effective communication on how to stop Ebola from spreading in Guinea, Liberia, Sierra Leone and other countries in the region (and perhaps beyond) where it may appear before this outbreak is under control. Research suggests that entertainment programs which capture the imagination (sometimes referred to as “transportation” as viewers experience a virtual reality) are especially effective as people who are engrossed in a drama are more open to both receiving information and to considering a change in attitudes and behaviors. Sometimes viewers even feel that they have a personal relationship with the fictional characters in programs. This phenomenon is known as “parasocial interaction” and can make media messages even more powerful. Entertainment education has been used extensively in the past for other health related challenges such as HIV/AIDS prevention and stigma reduction. The South African drama Soul Cityand MTV program Shuga are examples of popular television programs seen in the region which combine entertainment with well-developed health messages.

Communications strategies to address the Ebola outbreak are already using text messaging via mobile phones, community radio and TV programs, mobilization of community leaders and influencers, and door-to-door outreach. For instance, UNICEF and partners worked with Hip Hop star Takun in Liberia on messages and songs that target rumors and promote preventive behaviors. Youth volunteers are giving message-driven theater performances in communities and bus terminals. Barbers and hairdressers in Sierra Leone are being engaged in efforts to dispel rumors.

The scale of the challenge, however, requires both more extensive reach and even more impactful means. Local and regional media could leverage existing serials, soap operas, and the radio dramas which are popular where access to television remains limited. In some instances new, specialized content may be required to address specific cultural or language needs. Video clubs and mobile cinemas could share new film or video content beyond homes that receive broadcast or satellite TV. Combining entertainment education in radio, TV or film with a transmedia strategy that covers various communication platforms (Facebook, text messages, billboards, etc.) with consistent messages – sometimes using characters from a show to increase appeal and interest - is another approach that should be scaled up, as repetition reinforces key messages and increases impact. Furthermore, these should be combined and synergized with on-the-ground efforts such as social mobilization and training of community based health workers and local religious leaders, as well journalists, to compound reach and impact of the EE initiatives.

On August 1, 2014, the WHO warned that the Ebola “outbreak is moving faster than efforts to control it.” Increased use of communications tools to raise risk awareness among populations is not, of course, a substitute for public health interventions such as monitoring and reporting of cases of illness and death, isolating the infected, quarantine, safe burials, and infection control in hospitals. However, without adequate communications strategies, suspicion and fear will lead people to disregard advice on safe behaviors around the ill and the dead. (This blog from Vox provides a good discussion of the public health challenges surrounding Ebola and the need for a strong public education campaign. )

Contagion may seem an unlikely way to reduce the impact from Ebola in this and future outbreaks, but harnessing technologies, like mass entertainment media and cell phone networks, and using innovative approaches like entertainment education that incorporate insights from psychology offer the potential reach and impact that is urgently needed. Helping local media develop EE interventions could make a big difference in effectively transmitting public health messages to populations and securing their cooperation with urgently needed public health measures. Beyond the current crisis, public health capacities in all three countries and elsewhere in Africa (and beyond) will need substantial strengthening. Every country needs to be able to detect and control the next outbreak of Ebola or another disease; the costs to health, communities and economies of not having such capacity are much too high. Entertainment education could make a contribution then as well, by building awareness of health risks and resilience in communities; awareness which in turn could help make government leaders and their external partners accountable for the quality of public health capacities.

I want to congratulate the World Bank for this. Put yourselves in the flipflops of the people threatened by fear and an unseen enemy virus. Then the foreigners in spacesuits arrive looking like ghostly robots from outer space and they take away your sick children and dead family or neighbors. They spray chlorine bleach everywhere. They do not belong there at all because if you never saw them before, it's hard to grasp why and what they are doing.

It would be more acceptable and less insulting if the whole procedure were explained or revealed first in a manner that fits into local narratives. If there is a soap opera everyone watches it should have some episodes assoon as possible with the Ebola outbrake containment methods explained. The men in spacesuits are better accepted if fiirst seen on Tv or video than when they come for your dead mom.

The stupid public health leaflets posted by governments are known to be ignored. Here the World Bank surprises by an innovative idea that is client -oriented, for a change! Information acceptance by population would be low cost if produced locally (and foreign film-makers could donate time) and it may well actually work to make communities into better-informed and more powerful alies against this horrible disease epidemic.

I recommend this public television documentary on WGBHboston - EBOLA: THE PLAGUE FIGHTERS NOVA Discovery/Science/History (documentary) and imagine you are the Zaireois encountering outbreak of ebola in your town for the first time -
http://youtu.be/A9TClTX8UJc

Thank you for your detailed comment on the blog and for linking people to the Nova documentary. In the middle of the Nova program (about minute 26) it describes how a video on how local doctors were working to contain the illness had captured a large and rapt audience. The idea of working through existing media which you suggest - where audiences are already engaged with a soap opera or drama and its characters - is a great idea and a way to quickly and effectively communicate.

Development Communication is suprisingly a low priority topic for most UN Public Information people and commercial media orgs. I have experience of working for UNHCR PI Unit and was left with the impression that the UN tends to learn from the non-UN media practices. Whereas there is virtually no reverse stream of knowledge exchange.a This is actually why I dream to one day get Participant Media and the likes of Every Tribe Entertainment to attend media content markets along with the UN system PI people, as one team, promote this idea to commercial media reps. I also write about the important role that TV and film content plays in devcom http://steppesinsync.com/.../tv-and-film-help-unhcr-to.../ But blogging is certainly not enough. We need a proper movement linking media majors and humanitarian orgs

Thank you for your comment. The idea of linking development agencies' knowledge and expertise and communications teams with commercial entertainment media has been percolating at the World Bank for some time. The Innovation Competition held at the World Bank (to support WB staff innovators) awarded a grant to develop this idea in 2011. You may find this blog by Mahmoud Mohieldin, the WB's Corporate Secretary and President's Special Envoy on Development Goals and Financial Development, of interest as it discusses these ideas. http://globalpublicsquare.blogs.cnn.com/2011/10/04/learning-at-leisure-using-entertainment-education-to-empower-the-poor/

We have done several one-off projects too where the World Bank partners with commercial media for development impact. One such example is from South Africa where we worked with the soap opera Scandal! to include financial education messages. This experience was rigorously reviewed and found to be helpful in several dimensions. The paper can be found here: http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-6407
And a link to a report on the show is here: http://www.youtube.com/watch?v=ys5eSxTetF4

In the future, if we are able to move from one-off examples of partnerships with entertainment media, to a more sustainable dialogue, so that more entertainment media contain accurate, reliable and timely data on key issues facing their audiences, the impact would be much greater. I also think that development practitioners have knowledge, experiences and compelling stories from the field that could benefit the creative people in entertainment (writers, producers, directors) who are always looking for new ideas, and new stories to tell.

I wholeheartedly agree with Margaret and Olga about the potential of EE, especially now that this type of approach can be scaled up via mass media (through broadcast and mobile technology) but also brought down at the micro level via local screenings and community radios. Kudos to the WB for finally speaking up about this and yes, dedicating the 2015 WDR to the inclusion of this topic as it relates to behavior change. Twice I worked for the WB on an analysis on behavior change communication approaches in WB operations and both times I and others realized that too little is done too late with too few resources. Hopefully, this type of open discussion will persuade more key decision makers of the need to invest more in these types of approaches and in collecting evidence of their impact, not just for "passing messages" but rather for "opening up safe discussion spaces" and initiating "dialogue" around sensitive and sometimes controversial topics.